Monday, February 28, 2011

Time to give up

As I mentioned in an earlier post, sometimes a doctor is required to tell their patients that it is time to give up. The disease is winning and continuing to fight is not worth the burden of the side effects. This is one of the toughest decision any doctor, patient, or family member has to make...

They say you always remember your first. The first patient I lost was in her late 60's, which is young by modern medicine standards. She had been a heavy drinker for years and developed cirrhosis (i.e. liver disease). She came into hospital jaundiced with hepatic encepholopathy. When I first saw her, she was barely conscious and gasping for breath. I wouldn't have been surprised if she died that night. I probably wouldn't have remembered her if she did because, at that time, she wasn't my patient.

A few days later she started looking much better. She was still yellow from jaundice, but level of consciousness improved and she was coherent, chatty even. She constantly complained about pain, but she seemed otherwise well. Since she was out of her "rough patch", my team thought she was stable enough to be followed by a medical student, so she became my patient.

I had a chat with her and her husband and they were both overjoyed that she was doing so much better. They started telling me their life story: how they met, about their kids, about their dog. They mostly told me about their dog. They were both beaming. They were the couple that all hopeless romantics want to replicate when they go through their golden years. We had a nice talk.

Then the hepatologist, or liver doctor, came in to talk with them. He had a doom and gloom expression on his face. I thought he was just stressed out from working too much. He told the couple how the patient's Child-Pugh score, a prognostic indicator, showed that she didn't have very long to live. They were shocked. The husband asked if he should go back to their home, a day's travel away, to get more of their things so he could stay in town for longer. The hepatologist suggested he stay in the hospital; he didn't have time to go back home. Turned out the doom and gloom expression was warranted.

The patient went downhill quickly. She was struggling to breathe, constantly in pain, and often incoherent. The family was begging us to do anything and everything to save her. I understood their motivation, but I kept wondering why they couldn't see that nothing we did was helping... yet, they kept demanding we do more and more.

My attending came in to have a chat with them. He explained that we could no longer save the patient; her disease was progressing faster than our medications could treat it. He told them that we should stop trying to fix her and focus on making her comfortable... preparing her for death.

The way they were demanding more care, I thought the family would be up in arms. Instead, they all looked relieved, almost happy. In fact, they had realized that our medications weren't helping the patient, but they needed a doctor to tell them that it was ok to stop. They didn't want to be the ones to say "it's time for my wife/mom/sister to die"... They needed a doctor to tell them that it was okay to let their family member pass away, peacefully.

On that last day, the husband asked me if I could stay with the patient while he ran an errand. He wanted to make sure that she didn't die alone if he wasn't back in time. Normally, I refuse these types of requests because I have a lot of work to do in the hospital and it is generally unreasonable to ask a doctor (or med student) to sit with a patient while their family runs errands, but something in his expression stopped me from dismissing his request immediately. I asked him what errand he had to run.

"I have to go get our dog... she needs to see him before..."

I waited with her.

Fortunately, she was able to see her dog, in fact, she spent the whole night with him. She died peacefully the next morning surrounded by her friends and family.

Sunday, February 27, 2011

Internal Medicine as a Med Student

Internal medicine was my second rotation in third year. What is internal medicine? The most common definition is "adult medicine". That is a crappy definition because it tells you next to nothing. Every specialist, with the exception of pediatrics, practices some adult medicine. I think a better definition is the practice of medicine with regards to major internal organs and systems. Fields like cardiology, respirology, rheumatology, gastroenterology, and, in the past, neurology, are all sub-specialties of internal medicine.

Internists are the "doctor's doctor" because they focus their practice on being up to date with the latest research and understanding the complexities of how multiple systems or concurrent chronic illnesses are interacting with each other. When a hospitalized patient is really sick and their is no single definable cause, the internist is called.

The internal medicine rotation in third year is both loved and hated. It is loved because we are given tremendous responsibility, our work is held to a high standard, and we learn so much during this rotation. It is hated because we are given tremendous responsibility, our work is held to a high standard, and we learn so much during this rotation.

This is the first and only third year rotation where we are given our own patients. That is, a patient is admitted to hospital and the med student is the only member of the physician staff that sees the patient every single day. Of course, these patients are relatively stable and the senior resident and attending staff make sure to review the patients regularly so that their quality of care is ensured., but this is a rotation where we have our own patients. Since we are in charge of our patient's care, we are expected to be up to date with the latest understanding of the pathophysiology, diagnostic criteria, and treatment modalities for our patients' illnesses. We also have numerous educational sessions to teach us how to develop logical diagnostic approaches to different patient presentations, read ECGs, understand pathophysiology, etc.

In internal medicine, we also have to become comfortable with telling patients and their families that it is time to give up medical treatment and prepare for death. Something that is incredibly difficult to do at first, but becomes easier with time. However, regardless of how comfortable you get with the conversation, part of you always feels like you are giving up on the patient...

One thing I truly found remarkable through this rotation was how knowledgable the third year residents were. It blew me away how they could recite differentials, cite the latest clinical trials, and knew how to manage...well, everything. I found this remarkable because they seemed so much more knowledgable than their third year counterparts in surgery, which I will describe further in another post.

So my thoughts on my internal rotation:

1. Learn tons.
2. Actually feel like you can manage most non-complicated patients on your own.
3. Get to be the point person for patient care between for the physician team.

1. Finding time to learn what you need to manage your patients and to pass your exam.

This was a great rotation and I had very few complaints. In the end, I enjoyed every day of it and am now considering internal medicine as a future specialty.